Diagnosis of esophageal cancer

Diagnosing esophageal cancer usually begins with a visit to your family doctor. Your doctor will ask you about any symptoms you have and do a physical exam. Based on this information, your doctor may refer you to a specialist or order tests to check for esophageal cancer or other health problems.

The process of diagnosis may seem long and frustrating. It’s normal to worry, but try to remember that other health conditions can cause similar symptoms as esophageal cancer. It’s important for the healthcare team to rule out other reasons for a health problem before making a diagnosis of esophageal cancer.

The following tests are commonly used to rule out or diagnose esophageal cancer. Many of the same tests used to diagnose cancer are used to find out the stage, which is how far the cancer has progressed. Your doctor may also order other tests to check your general health and to help plan your treatment.

Health history and physical exam

Your health history is a record of your symptoms, risk factors and all the medical events and problems you have had in the past. In taking a health history, your doctor will ask questions about a personal history of:

symptoms that suggest esophageal cancer

gastroesophageal reflux disease (GERD)

Barrett’s esophagus

smoking

alcohol use

tylosis, which is a rare inherited disease that causes scaly patches (called hyperkeratosis) on the palms or soles and growths with finger-like projections (called papillomas) in the esophagus

irritation, injury or damage to the esophagus (for example, swallowing lye as a child)

Plummer-Vinson syndrome (also called Paterson-Kelly syndrome), which is a rare syndrome that affects the mucous membranes of the esophagus

Complete blood count (CBC)

A CBC measures the number and quality of white blood cells, red blood cells and platelets. A CBC is done to check for anemia from long-term, or chronic, bleeding. A CBC may also be done to set a baseline to compare with blood tests done during and after treatment to check the effects of therapies that can lower blood cell counts.

Blood chemistry tests

Blood chemistry tests measure certain chemicals in the blood. They show how well certain organs are functioning and can help find abnormalities.

Liver function tests may be done to stage esophageal cancer. These tests measure lactic dehydrogenase (LDH), alanine aminotransferase (ALT), aspartate transaminase (AST), alkaline phosphatase (ALP) and bilirubin to check how well the liver is working. Higher levels of these enzymes may mean the cancer has spread to the liver. Higher levels of ALP may also mean the cancer has spread to the bone.

Upper GI series

An upper gastrointestinal (GI) series may also be called a barium swallow. Barium is a thick, chalky liquid that coats the inside of organs and shows their outline clearly on an x-ray. During an upper GI series, you swallow barium and then a technician takes x-rays of the upper GI tract, including the esophagus, stomach and upper small intestine.

An upper GI series is often the first diagnostic test used to check for esophageal cancer. It can show:

a break in the surface of the esophagus (called ulceration)

narrowing, or stricture, of the esophagus

the location and general size of a tumour in the esophagus

an abnormal opening from the esophagus into the trachea (called tracheoesophageal fistula)

Upper GI endoscopy

An upper gastrointestinal (GI) endoscopy is done to examine the upper GI tract, including the esophagus, stomach and the first part of the small intestine (called the duodenum). This procedure is sometimes called an esophagogastroduodenoscopy (EGD) because it examines all of these organs. It may also be called an esophagogastroscopy when only the esophagus and stomach are examined.

An upper GI endoscopy uses an endoscope, which is a flexible tube with a light and lens on the end. The doctor passes the endoscope through the mouth and down the throat into the esophagus. Before the procedure, a local anesthetic is sprayed onto the back of the throat to numb it. Intravenous (IV) medication may be given as well.

An ultrasound may be done with an endoscope (called endoscopic ultrasound, or EUS) during upper GI endoscopy. The ultrasound is done to see how deep into the layers of the esophagus the tumour has grown and if the cancer has spread to any nearby lymph nodes. Biopsies may be done by a needle.

EUS uses an endoscope with an ultrasound probe. Ultrasound uses high-frequency sound waves to make images of structures in the body. It can provide detailed information about the location, size and depth of the tumour. It can also show doctors if the cancer has spread to surrounding lymph nodes or tissues.

EUS is often done at the same time as an upper GI endoscopy. The doctor may also do fine needle aspiration through the wall of the esophagus during EUS to check for cancer in surrounding lymph nodes.

Biopsy

During a biopsy, the doctor removes tissues or cells from the body so they can be tested in a lab. The report from the lab will confirm whether or not cancer cells are present in the sample.

Endoscopic biopsy removes tissue from the esophagus through an endoscope during an upper GI endoscopy or endoscopic ultrasound (EUS). With EUS, the doctor may also do fine needle aspiration through the wall of the esophagus to check for cancer in surrounding lymph nodes. A brush biopsy may also be used. The doctor inserts and removes the needle or brush through the endoscope as they look inside the esophagus. The needle or brush is used to remove cells from an abnormal-looking or suspicious area.

CT-guided biopsy removes tissue samples from abnormal or suspicious lymph nodes using a CT scan to guide the biopsy needle.

Laparoscopic biopsy removes tissue samples from areas in the abdomen using a laparoscope. It may be used to see if cancer has spread to the abdomen.

CT scan

A computed tomography (CT) scan uses special x-ray equipment to make 3-D and cross-sectional images of organs, tissues, bones and blood vessels inside the body. A computer turns the images into detailed pictures.

Doctors may do a CT scan of the chest and abdomen, and sometimes the pelvis. It is used to find out the size and location of an esophageal tumour and see if the cancer has spread to surrounding lymph nodes, nearby organs or tissues. It can also be used to see if there is cancer in more distant organs such as liver, lungs or adrenal glands.

A dye (called a contrast medium) may be used to make certain structures show up better on the scan. It may be injected into a vein or you may be asked to drink the contrast medium. The contrast medium coats the esophagus, stomach and small intestine. This will help the doctor examine the lining of the upper GI tract for any areas of narrowing or ulceration. Tell your doctor or the radiology staff if you know you are allergic to contrast mediums.

PET scan

A positron emission tomography (PET) scan uses radioactive materials called radiopharmaceuticals to look for changes in the metabolic activity of body tissues. A computer analyzes the radioactive patterns and makes 3-D colour images of the area being scanned.

A PET scan can be combined with a CT scan (called PET/CT). Newer machines can do a PET and CT scan at the same time. PET/CT provides more detailed information about structures in the body that are sometimes hard to see with PET alone.

Pulmonary function tests

Pulmonary function tests (also called lung function tests) check how well the lungs are working. These tests are important if the doctors are considering surgery as a treatment option for esophageal cancer. These tests help make sure you are healthy enough to have surgery.

Heart function tests

The doctors may order heart function tests to make sure you are healthy enough to have and recover from surgery. Electrocardiogram (ECG) measures the electrical activity in the heart. Echocardiogram (echo) uses ultrasound to look at the structure and motion of the heart.

Thoracoscopy

A thoracoscopy is a procedure that allows the doctor to look inside and take samples from the chest cavity. The doctor makes a small cut through the chest wall and places a tube-like instrument with a light and lens, called a thoracoscope, into the chest between 2 ribs.

Doctors usually do a thoracoscopy to look for cancer in lymph nodes and other organs near the esophagus inside the chest. They may also take biopsy samples during thoracoscopy.

Laparoscopy

A laparoscopy is a procedure that uses an endoscope (a thin, tube-like instrument with a light and lens) to examine or treat organs inside the abdomen and pelvis. It allows doctors to examine and remove internal organs through several small incisions, or cuts. Doctors may also take biopsy samples during a laparoscopy (called laparoscopic biopsy).

A laparoscopy is used to accurately stage esophageal cancer so doctors can plan treatment. It may find cancer that has spread to other parts of the abdomen that wasn’t seen on a PET or CT scan.

Bronchoscopy

A bronchoscopy is a procedure that allows doctors to look inside the trachea (windpipe) and bronchi (large airways of the lung) to look for abnormal areas. The doctor passes a tube-like instrument with a light and lens, called a bronchoscope, through the mouth or nose into the airways to the lungs.